ASIAN DEVELOPMENT FOUNDATION COLLEGE

COLLEGE OF NURSING
TACLOBAN CITY

A CASE STUDY
ON
COMMUNITY ACQUIRED PNEUMONIA

PRESENTED TO:
JEFFRY RAPANAN, RN

PRESENTED BY:
NAOMI ANN G. BARSANA
CHRISTINE YSABELLE A. BIONG
JESRA MAE S. BOLO
CLENT S. BORREL
AHRON S. CAJEPE
CATHRINA P. COCHERO
JOVI ANN Q. LAGUMBAY
AINHEL O. CAMARO
JERCEL V. BUTALON
(CLINICAL GROUP 2)

OCTOBER 02, 2023

GENERAL OBJECTIVE
After presentation and discussion of the case, the students’ knowledge for Community Acquired
Pneumonia will be enhanced and further understood through comprehensive, detailed, and accurate
History Taking, Gordon’s Typology of 11 Functional Health Patterns, presentation of Physical
Examination and ROS results, interpretation of Laboratory Test results and other specific tests done, and
the different treatment modalities given to the patient.

SPECIFIC OBJECTIVES

 To accurately present the patient’s biographical profile along with a comprehensive nursing
health history
 To present the patient’s response to each of the given basis of Gordon’s Typology of 11
Functional Health Patterns
 To present the detailed and accurate History Taking
 To present the detailed presentation of Physical Examination and ROS results
 To develop effective communication and patient education skills to help individuals and their
families for caring to the patient
 To identify, prioritize and implement nursing interventions for the patient

INTRODUCTION TO THE DISEASE PROCESS

DEFINITION

Pneumonia

Types of pneumonia

CLINICAL MANIFESTATIONS

COMPLICATIONS

MEDICAL MANAGEMENT

NURSING MANAGEMENT
 COMPREHENSIVE NURSING HEALTHHISTORY

I. PATIENT’S DEMOGRAPHIC PROFILE

Patient Name: Patient F.T.D
Sex: Female
Date of Birth: February 26, 1957
Age: 67 years old
Place of Birth: Palo, Leyte
Permanent Address: #0045 Reñero Street
Nationality: Filipino
Religion: Roman Catholic
Occupation: Housewife
Admission Date and Time: September 22, 2024 and 12:42 PM
Health Care Financing: PhilHealth
Source(s) of Medical Care: Divine Word Hospital
Chief Complaint: Black Tarry Stool and Vomiting
ADMITTING DIAGNOSIS:
FINAL DIAGNOSIS: Hypovolemic Shock Secondary to GI Losses and B
Latest Vital Signs:
BP: 110/70 mmHg RR: 19cpm PR: 65bpm TEMP: 37.3°C O²SAT: 90%

II. NURSING HEALTH HISTORY

A. HISTORY OF PRESENT ILLNESS
3 days prior to consultation the patient experienced consistent high fever that has temperature of
38.9, cough and colds. the mother gave her a Paracetamol (Tepmra) 1ml as a first medication to relieve
the symptoms of the patient. The patient still experiencing soft cough and fever. 1 day prior to
consultation the patient has still fever that has a temperature of 38.5 soft cough and cold that was not
relieve by taking medication. Resulting this for admitting the patent at Devine World Hospital for
medical care.
Her vital signs upon admission were:

Temperature – 38.5°C

Pulse Rate – 187 bpm

Respiratory Rate –36cpm

Oxygen Saturation – 98%

B. PAST MEDICAL HISTORY

Patient A.T.D has no problems at birth, she was diagnosed with Covid-19 Year 2022 last week of
October and was hospitalized for 1 week. Patient was fully vaccinated and immunized with flue vaccine
2 doses. She had an accident when she was 9 months old, specifically July,2023, she had a fall from the
stairs that leaves bruises on her upper extremity. No surgeries nor allergies were noted. Patient had
taken Paracetamol (Tempra) 1ml before admission. No other maintenance drug was noted.
 C. FAMILY HISTORY

Hypertension in his paternal side was noted, Diabetes Mellitus in her maternal side. His father
and mother are still alive and does not have any serious conditions that may lead to fatality .No other
genetic diseases were noted.

D. LIFESTYLE AND HEALTH PRACTICES

a. ACTIVITY

Patient FDT doesn’t have a planned exercise, she go out and play whit her cousin as a mourning
routine. Afterwards she was taken by her grandparents for walking round their subdivision. Everyday her
activity starts from 6 am until 8pm, watching cartoon movies and playing with her cousins. Her current
weight is 10.5 kg while his current body length is 78 cm.

b. FOOD

Patient FDT parents prepares for her meals. She eats three to five meals a day with snacks in
between. She prefers to eat rice meals with vegetables and meats. Patient reported only eating healthy
foods because her mother is the one who prepares the meal for her. She doesn’t have a vitamins or
supplements that is taken regularly.

c. SELF

Patient FDT has jolly personality, she likes talking with her family. She also enjoys singing long
with her favorite kid show. Patient also show a strong bond to each member of her family. Her social
activities for fun and relaxation include watching television. One of her stressors in life is raising their
child and everyday’s activity, but she always prays.
d. RESIDENCY
The patient’s environment is free from pollution. But according to her, there is a presence of
vectors such as mosquitos in their neighborhood. The area where their house is located is not congested.
The structure of their house is enough to accommodate their family

E. PSYCSOSOCIAL HISTORY
Patient D.A.A is in the stage of “Intimacy vs. Isolation” according to Erik Erikson’s
Psychoanalytic Stages of Development. The important event in this stage is the ability to enter into a
romantic relationship and form a family. And adults would contemplate, "will I be loved or will I be
alone?". In this stage, an adult one forms an intimate and reciprocal relationships with romantic partners
in adulthood as well as a circle of friends, acquaintances, family members, and others which they can
form bonds and are comfortable with mutual dependency. They open and share oneself to others, as well
as the willingness to commit relationships and make personal sacrifices for the sake of these relationships.
But sometimes things don't go smoothly and struggle to close relationships that they might experience
rejection or other responses that cause them to withdraw. Adult’s isolation on the other hand, would be
marked by a lack of social connections, poor or unhealthy relationships, and a general lack of social
support. No matter what could be the cause, it can have a detrimental impact on their life and may lead to
feelings of loneliness and even depression.

In the patient’s case she has 1 daughter and recently pregnant with her second child. She accepts
her role as a wife and a mother, despite her condition, being supportive is one of her ways of taking care
of her children. Patient also talks to her husband whenever she has a problem and needs an advice. She
also has a lot of friends in their neighborhood and gets along with them. She has no problem when it
comes to her family and peers close bonds. Her relationship also with her husband is strong as they
support and always there for each other. By that, these can be proved that she has not struggling to her
close relationships and no fear of rejection.

Recently, patient and her family stays in Tacloban City to get the treatments that she needs. She
derives pleasure from selected social activities for fun like watching television, reading, binge eating and
sharing funny stories to her husband. There were no changes in her cognition to be found.

III. GORDON’S TYPOLOGY OF 11 FUNCTIONAL HEALTH PATTERNS

HEALTH PATTERNS BEFORE THE COURSE AFTER THE COURSE OF
OF ILLNESS ILLNESS
1. Health Perception – Patient FTD viewed health as a While the patient is in the
Health Management Pattern state in which she can perform hospital she cant define her
her work daily. The patient health as health. She scored
scored herself 8/10 since she herself 5/10. She is willing to
had done operation years ago, accept and listen to health
hysterectomy. If she experience teaching and shows interest to
fever, cough and colds she take recover easily, she comply with
OTC drugs such as (neozep, all her medications in orders
paracetamol and solmux) she from the healthcare team.
rarely visits a doctor to have a
check up and seek for medical
assistance. Patient FTD cannot
recall if she is fully immunize.
2. Nutritional – TYPICAL FOOD INTAKE TYPICAL FOOD INTAKE
Metabolic Pattern Patient FDT prepares her Patient was prescribed with diet
family’s meal. She eats three as tolerated.
times a day with snacks in
between. She reports to be TYPICAL FLUID INTAKE
eating healthy foods like meats Patient had consumed a low
and vegetable. She does not take amount of water that estimated
any vitamins or supplements. to be in 20L per bottle – she can
TYPICAL FLUID INTAKE consume 3 bottles a day.
Patient drinks 8 glasses of water
a day. She does not like drinking
milk or coffee.
3. Elimination Pattern BOWEL ELIMINATION BOWEL ELIMINATION
PATTERN PATTERN
Patient FDT reported to have no Patient FDT reported to have no
difficulty in defecating. Her difficulty in defecating. Her
bowel elimination occurs twice bowel elimination occurs once a
a day with a yellow to brown day with a yellow to brown stool
 stool that has a soft to firm that has a soft to firm
consistency. The color of her consistency. The color of her
stool depends on the food she stool depends on the food she
is eating. is eating.
URINARY ELIMINATION URINARY ELIMINATION
Patient has no difficulty in Patient has no difficulty in
urinating. She reports to be urinating. She reports to be
urinating 4-5 times a day. Her urinating 6-7 times a day. Her
urine is yellowish in color and is urine is yellowish in color and is
clear in transparency. clear in transparency.
PERSPIRATION
Patient easily perspires, and her PERSPIRATION
perspiration increases whenever Patient shows no difficulty in
he performs a physical activity perspiration.

4. Activity – Exercise Patient FDT exercise is doing During the disease she cannot
Pattern house chores. perform her duty.
5. Sleep – Rest Pattern Patient reports to be awaked at 5 Patient FDT does not have a
in the morning together with her continuous sleep. She claims to
husband, she prepares meal for sleep around 10 PM.
them and do some household
chores. Patient’s reports that her
sleep patterns start’s at 8 PM
and ends at 5 AM.
6. Cognitive – Patient has no difficulty in Patient has no difficulty in
Perceptual Pattern hearing and vision. Her memory Hearing. There is no difficulty
and concentration are at its in her vision. Her memory and
optimum level. She easily concentration are in intact.
makes important decisions. Sometimes, patient make jokes
in conversations to lighten up
the mood.
7. Self-Perception and Patient FDT is a funny person One of her stressors in life is her
Self-Concept she usually makes jokes every condition. She feels that she is
Pattern time she talks to someone. Her unable to perform her duties as a
social activities for fun and mother and a partner. She does
relaxation include watching not engage in unhealthy coping
television, reading, binge eating strategies.
and sharing funny stories to her
husband. Her coping
mechanisms was making herself
busy in doing household chores.
8. Roles – ROLE TO OTHERS ROLE TO OTHERS
Relationships Patient FDT plays the role of a She accepts her role as a
Pattern mother to her children and a wife and a mother, despite her
wife to her husband, they condition. The patient is well
maintain a god communication, supported by her family. She
there are no conflicts among received a positive
them and shares her idea when it reinforcement and provided her
comes to decision making. comfort and reassurance.
ROLE OF OTHERS ROLE OF OTHERS
Whenever she has a problem, Patient talks to her husband
she consults her partner and asks most regarding her condition.
for advice. Patient has a lot of
friends in their neighborhood.
9. Sexuality – The had her first menstruation at
Reproductive 16. When she still had her
Pattern menstruation she consumed 3
pads a day. Now, she is
menopause because her uterus
has been removed.
[Link] – Stress Patients reports to be indulging The biggest change in
Tolerance Pattern herself in doing household patient FDT ‘s life is the
chores. She shares her problem situation that she is facing right
with her husband to cope. now. Due to her condition, she
does not engage in household
task. She still shares her
problems and concerns to her
 husband
to cope.
11. Values – Beliefs Patient FDT does not easily get Patient DFT admitted that she
Pattern what she wants in life. However, cannot attend mass.
she perseveres to provide the
needs of her family. Patient is a
Roman Catholic. She attend
mass twice a month with her
family.

I. PHYSICAL EXAMINATION

CATEGORY FINDINGS

Vital Signs  Temperature - 36.2°c

 Pulse Rate - 73cpm
 Respiratory Rate - 20bpm
 Blood Pressure- 110/70

General Appearance  Pale color

 Presence of body weakness
 Conscious
 Hair with normal texture and in normal
distribution
 Mild paleness with the nail is present

Head, Eyes, Ears, Nose, Throat  Head is symmetric, round, erect, and in
midline and appropriately related to body size
(normocephalic).
 No lesions are visible.
 The head is normally hard and smooth,
without lesions.
 Facial wrinkles are prominent
 No visual problems
 No difficulty of hearing

Neck  Neck is symmetric, with head centered and

without bulging masses
 The thyroid cartilage, cricoid cartilage moves
upward symmetrically as the client swallows
 Trachea is in the midline
 There is no swelling or enlargement and no
tenderness

Chest and Lungs  No abnormal curvature of spine.

 No nipple deformity or discharge.
 Clear breath sounds
 RR- 20 breaths/min.

Cardiovascular  PR – 73 beats/min.
 No extra sounds or murmurs
 Regular rhythm

Abdomen  Presence of lesions due to surgery

 No abnormal tympany
 Genitourinary  Vagina without lesions.
 No vaginal discharge.
 No urethral discharge

Rectal  No difficulty defecating

 No external lesions
 No tenderness or masses

Musculoskeletal  Body weakness present

 Skin warm is warm and dry.

Extremities/Skin  No abnormal pigmentation, bleeding, rash, or
other lesions.
 Presence of pallor
 No ulcers noted
 No edema

Neurologic  Alert, oriented to time, place, person, and

situation
 Recent and remote memory intact
 Good insight and cognitive function
 No aphasia, dysarthria, or hoarseness

II. REVIEW OF SYSTEMS

Skin, hair, and nails:
 No report of problems with skin, hair, or nails
Head and neck:
 Presence of headaches, swelling, stiffness of neck, difficulty swallowing, sore throat, enlarged
lymph nodes.
Eyes:
 Denies visual problems. Denies eye infections, redness, excessive tearing, halos around lights,
blurring, loss of side vision, moving black spots/ specks in visual fields, flashing lights, double
vision, and eye pain
Ears:
 No signs of difficulty in hearing.
Mouth, throat, nose, and sinuses:
 Denies bleeding of gums or other dental problems, sore throats, mouth lesions, hoarseness,
rhinorrhea, nasal obstruction, frequent colds, sneezing or itching of eyes, ears, nose, or throat, nose
bleeds, nor snoring.
Thorax and lungs:
 No difficulty of breathing, no orthopnea, hemoptysis, respiratory infections.
Heart and neck vessels:
 Latest blood pressure was 110/80
Peripheral vascular:
 Presence of edema on both feet
Abdomen:
 Denies difficulty swallowing, nausea, gas, jaundice, Reports of vomiting.
Musculoskeletal:
 Reports body weakness.
Neurologic:
 Denies feelings of anger or suicidal thoughts.
 Denies concussions, headaches, difficulty speaking, memory problems, strange thoughts and/or
actions.
Female genitalia:
 Denies sexual problems; sexually transmitted infections (STIs); dribbling or incontinence.
 Denies lesions, vaginal discharge, masses, or tenderness
 Denies hernia anus, rectum, and prostate:
 Reports having once or twice a day of bowel movement

PRIORITY SIGNS AND SYMPTOMS FOCUSED ON PATIENT

1. Cervix dilation
Contractions and dilation (opening) of the cervix before 37 weeks of pregnancy
are considered preterm, or premature, labor. A normal pregnancy lasts about 40 weeks
after the first day of the last period (38 weeks after fertilization). Preterm labor
contractions lead to changes in the cervix. The changes include effacement (thinning of
the cervix) and dilation (opening of the cervix).

2. Vaginal Bleeding
Vaginal bleeding may be a sign of labor. If labor starts before 37 weeks of
pregnancy, it is called preterm labor. Other signs of preterm labor include the following:
Change in vaginal discharge (it becomes watery, mucus-like, or bloody) or increase in
amount of vaginal discharge. Bleeding from the vagina in the second or third trimester.
Preterm premature rupture of the membranes (also called PPROM). Premature rupture of
membranes (also called PROM) is when the amniotic sac around your baby breaks (your
water breaks) before labor starts. PPROM is when this happens before 37 weeks of
pregnancy.

3. Low Backache
The backache you experience in preterm labor is usually located in the lower
back. It may come in waves and may travel to the front of your abdomen. This ache is not
relieved by changing your position. Back labor tends to be centralized in your lower back
and may feel like intense pressure or acute pain. Some women feel spasms or
contractions in their back while also feeling them in their abdomen.
 ANATOMY AND PHYSIOLOGY OF THE AFFECTED SYSTEM
FEMALE REPRODUCTIVE SYSTEM - EXTERNAL PARTS
The function of your external genitals are to protect the internal parts from infection and allow sperm
to enter your vagina. Your vulva is the collective name for all your external genitals. A lot of people
mistakenly use the term “vagina” to describe all female reproductive parts.

The main parts of your vulva or external genitals are:

 Labia majora: Your labia majora (“large lips”) enclose and protect the other external
reproductive organs. During puberty, hair growth occurs on the skin of the labia majora, which
also contain sweat and oil-secreting glands.
 Labia minora: Your labia minora (“small lips”) can have a variety of sizes and shapes. They
lie just inside your labia majora, and surround the opening to your vagina (the canal that joins the
lower part of your uterus to the outside of your body) and urethra (the tube that carries pee from
your bladder to the outside of your body). This skin is very delicate and can become easily
irritated and swollen.
 Clitoris: Your two labia minora meet at your clitoris, a small, sensitive protrusion that’s
comparable to a penis in men or people assigned male at birth (AMAB). Your clitoris is covered
by a fold of skin called the prepuce and is very sensitive to stimulation.
 Vaginal opening: Your vaginal opening allows menstrual blood and babies to exit your body.
Tampons, fingers, sex toys or penises can go inside your vagina through your vaginal opening.
 Hymen: Your hymen is a piece of tissue covering or surrounding part of your vaginal opening.
It’s formed during development and present during birth.
 Opening to your urethra: The opening to your urethra is the hole you pee from.

INTERNAL PARTS

 Vagina: Your vagina is a muscular canal that joins the cervix (the lower part of uterus) to the
outside of the body. It can widen to accommodate a baby during delivery and then shrink back to
hold something narrow like a tampon. It’s lined with mucous membranes that help keep it moist.
 Cervix: Your cervix is the lowest part of your uterus. A hole in the middle allows sperm to
enter and menstrual blood to exit. Your cervix opens (dilates) to allow a baby to come out during
a vaginal childbirth. Your cervix is what prevents things like tampons from getting lost inside
your body
 Uterus: Your uterus is a hollow, pear-shaped organ that holds a fetus during pregnancy. Your
uterus is divided into two parts: the cervix and the corpus. Your corpus is the larger part of your
uterus that expands during pregnancy.
 Ovaries: Ovaries are small, oval-shaped glands that are located on either side of your uterus.
Your ovaries produce eggs and hormones.
 Fallopian Tubes: These are narrow tubes that are attached to the upper part of your uterus and
serve as pathways for your egg (ovum) to travel from your ovaries to your uterus. Fertilization of
an egg by sperm normally occurs in the fallopian tubes. The fertilized egg then moves to the
uterus, where it implants into your uterine lining.